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Group

(GEM) Activities Of Daily Living

LONG TERM CARE /NURSING HOME

(GEM) Instrumental Activities Of Daily Living Scale

LONG TERM CARE /NURSING HOME

10-10 Nursing Ambulatory Care

NURSING

Acute Coronary Syndrome

SPECIALTIES

Acute Gout Note

PRIMARY CARE

Addictions Treatment Center Note

SUBSTANCE ABUSE

ADHC Initial Nursing Assessment

LONG TERM CARE /NURSING HOME

Admission Assessment Nursing

NURSING

Adult Day Health Care Interdisciplinary Care Plan

LONG TERM CARE /NURSING HOME

Adult Day Health Care RN Monthly Note

LONG TERM CARE /NURSING HOME

Advance Directive Note

GENERAL

Adverse Drug Reaction Note

GENERAL

Allergy Desensitization Schedule

SPECIALTIES

Allergy Testing

SPECIALTIES

Alternative OMFS Clinic Note

DENTAL

Amputee Clinical Pathway

SURGICAL/PROCEDURES/ANESTHESIA

Anesthesia Pre/Post Op Assessment

SURGICAL/PROCEDURES/ANESTHESIA

Anticoagulation Clinic Note

CARDIOLOGY/PULMONARY

Attending Brief Addendum to Resident Note

GENERAL

Attending Detailed Addendum to Resident Note

GENERAL

Audiology Assessment

AUDIOLOGY/SPEECH

Audiology Diagnostic Test

AUDIOLOGY/SPEECH

Audiology Evaluation

AUDIOLOGY/SPEECH

Audiology Exam Note

AUDIOLOGY/SPEECH

Audiology Progress Note

AUDIOLOGY/SPEECH

Audiology Walk-In Clinic

AUDIOLOGY/SPEECH

BDI. See Beck Depression Inventory Self-Assessment

MENTAL HEALTH/SOCIAL WORK

Beck Depression Inventory Self-Assessment

MENTAL HEALTH/SOCIAL WORK

BHC Initial Intake

MENTAL HEALTH/SOCIAL WORK

Biophysical Assessment

NURSING

Bladder Incontinence Assessment

LONG TERM CARE /NURSING HOME

Blood Component/Transfusion Order

GENERAL

Braden Scale

NURSING

Braden Scale(Abridged)

NURSING

Braden Scale/Skin Problems

NURSING

Brain Death Note

GENERAL

Cardiac Perfusion Worksheet A

CARDIOLOGY/PULMONARY

Cardiac Perfusion Worksheet B

CARDIOLOGY/PULMONARY

Cardiac Rehab. Note

CARDIOLOGY/PULMONARY

Cardiac Stress Note

CARDIOLOGY/PULMONARY

Cath Lab Nursing Procedure

NURSING

Cath Lab Nursing Recovery Note

NURSING

Cath Lab Post-Procedure Note

NURSING

Cath Lab Pre-Procedure Note

NURSING

Center for Epidemiologic Studies Depression Scale

MENTAL HEALTH/SOCIAL WORK

Cerebrovascular Duplex Evaluation

CARDIOLOGY/PULMONARY

Chemotherapy Admission Note

SPECIALTIES

Chemotherapy Assessment

NURSING

Chemotherapy/Biotherapy Administration Post-Assess

SPECIALTIES

Chemotherapy/Biotherapy Record

SPECIALTIES

Chemotherapy/Biotherapy Record Day 2+

SPECIALTIES

Chiropractic Consult

SPECIALTIES

Clinical Opiate Withdrawal Scale (COWS)

SUBSTANCE ABUSE

Clinical Restraint Note

GENERAL

Clopidogrel Restricted Drug Request

CARDIOLOGY/PULMONARY

Combined Nursing Assessment

NURSING

Community Residential Care Follow Up

LONG TERM CARE /NURSING HOME

Comprehensive History and Physical Examination

GENERAL

Comprehensive Initial Nursing Assessment

NURSING

Comprehensive Nursing Assessment/Admission

NURSING

Comprehensive Women’s Health

PRIMARY CARE

Contract Nursing Home Follow-Up

LONG TERM CARE /NURSING HOME

Daily Nursing Assessment

NURSING

DAR Intake and Output

NURSING

Day Flow Sheet

NURSING

Day Treatment Note

MENTAL HEALTH/SOCIAL WORK

Dental Education Note

DENTAL

Dental History Intake

DENTAL

Dental Hygiene Note

DENTAL

Dental Implant Treatment Note

DENTAL

Dental Nursing Home Note

DENTAL

Dental Procedure Note

DENTAL

Diabetic Education

SCREENING/EDUCATION

Diabetic Foot

PRIMARY CARE

Discharge Instruction Note

NURSING

Discharge Instructions

NURSING

Discharge Instructions (Cheyenne)

NURSING

Discharge Instructions (SAVAHCS)

NURSING

Discharge Plan

GENERAL

DNR Note

GENERAL

Education Assessment

SCREENING/EDUCATION

EEG Report

SPECIALTIES

Electro-Convulsive Therapy Post-Procedure Note

CARDIOLOGY/PULMONARY

Electro-Convulsive Therapy Pre-Procedure Note

CARDIOLOGY/PULMONARY

Emergency Room Assessment

NURSING

Endodontic Treatment Note

DENTAL

ENT Consult

SPECIALTIES

Erythropoietin Restricted Drug Request

GENERAL

Extended Care Admission Screening Assessment

LONG TERM CARE /NURSING HOME

Extended Care Admission Screening Assessment 2

LONG TERM CARE /NURSING HOME

Extended Care Nursing Monthly Summary

LONG TERM CARE /NURSING HOME

Falls Risk Reassessment

NURSING

Fixed Prosthodontics Note

DENTAL

General Dentistry Examination

DENTAL

Geriatric Assessment for Chemotherapy

SPECIALTIES

Geriatric/Extended Care Nursing Assessment

LONG TERM CARE /NURSING HOME

Geropsychology Assessment

MENTAL HEALTH/SOCIAL WORK

GI Nurse Endoscopy Post-Procedure

SPECIALTIES

GI Nurse Endoscopy Procedure

SPECIALTIES

GI Nurse Pre-Procedure Endoscopy

SPECIALTIES

GI Telephone Follow-Up

SPECIALTIES

Graphical Pain Assessment

GENERAL

Health Promotion Screening Note

SCREENING/EDUCATION

Healthcare for Homeless Veterans

MENTAL HEALTH/SOCIAL WORK

Heparin Protocol Infusion Rate Change

NURSING

Heparin Weight Based Protocol Initiation

NURSING

History and Physical

PRIMARY CARE

Holter Tape Cardiac Note

CARDIOLOGY/PULMONARY

Home Base Initial Assessment

LONG TERM CARE /NURSING HOME

Home Based Daily Nurse Note

HOME HEALTH

Home Based Post Fall Note

HOME HEALTH

Home Based Primary Care

HOME HEALTH

Home Based Primary Care Initial PT Assessment

HOME HEALTH

Home Based Primary Care Nursing Assessment

HOME HEALTH

Home Based Primary Care Reassessment

HOME HEALTH

Home Care Discharge Instructions

HOME HEALTH

Home Care Provider Visit Note

LONG TERM CARE /NURSING HOME

Home Oxygen Therapy

HOME HEALTH

Homemaker/Home Health Aide Consult

HOME HEALTH

Hospice and Palliative Care

NURSING

Hospice and Palliative Care H&P

LONG TERM CARE /NURSING HOME

Hospice Nursing Admission Note

LONG TERM CARE /NURSING HOME

ICU Nursing Shift Assessment

NURSING

Impact Pre-Op SDS RB/NP/PA

NURSING

Infectious Disease HIV Initial History & Physical

SPECIALTIES

Infectious Disease HIV Post-Test Counseling

SPECIALTIES

Infectious Disease HIV Pre-Test Counseling

SPECIALTIES

Informed Consent Note

SURGICAL/PROCEDURES/ANESTHESIA

Initial Home Health Visit

HOME HEALTH

Initial Inpatient Nutrition Assessment

NUTRITION (DIETETICS)

Initial Nursing Assessment Part I

NURSING

Initial Nursing Assessment Part II

NURSING

Initial Nursing Assessment Part III

NURSING

Initial Outpatient Plan

MENTAL HEALTH/SOCIAL WORK

Initial Psycho Social Assessment

MENTAL HEALTH/SOCIAL WORK

Inpatient Antibiotic Note

GENERAL

Inpatient Enteral/Parenteral Note

NUTRITION (DIETETICS)

Inpatient Pain Assessment

NURSING

Instrumental Swallow Study

AUDIOLOGY/SPEECH

Interdisciplinary Acute Care Plans

LONG TERM CARE /NURSING HOME

Interdisciplinary Patient Assessment

NURSING

Invasive Procedure Note

SURGICAL/PROCEDURES/ANESTHESIA

Long Term Care ADL

LONG TERM CARE /NURSING HOME

Long Term Care History and Physical

LONG TERM CARE /NURSING HOME

LTC Assessment Criteria and Care Plan

LONG TERM CARE /NURSING HOME

LTC Nursing Falls Risk Assessment

LONG TERM CARE /NURSING HOME

LTC Provider Post Fall Assessment

LONG TERM CARE /NURSING HOME

LTC Rehab Note

LONG TERM CARE /NURSING HOME

Maxillofacial/Equilibration Note

DENTAL

Medical Pre-Op Provider Path

PRIMARY CARE

Medical/Surgical Restraint

SURGICAL/PROCEDURES/ANESTHESIA

Mental Health 4AB Master Care Plan

MENTAL HEALTH/SOCIAL WORK

Mental Status Exam

MENTAL HEALTH/SOCIAL WORK

MH Follow-Up

MENTAL HEALTH/SOCIAL WORK

MH Group Note (national)

MENTAL HEALTH/SOCIAL WORK

MH History and Physical Examination

MENTAL HEALTH/SOCIAL WORK

MH Individual Note (national)

MENTAL HEALTH/SOCIAL WORK

MH Medication Management Note (national)

MENTAL HEALTH/SOCIAL WORK

MH Nursing Assessment Pt 1

MENTAL HEALTH/SOCIAL WORK

MH Nursing Assessment Pt 2

MENTAL HEALTH/SOCIAL WORK

MH Outpatient Admissions Note

MENTAL HEALTH/SOCIAL WORK

MH Prescriber Note (national)

MENTAL HEALTH/SOCIAL WORK

MHICM/Psychosocial Assessment & Treatment Plan

MENTAL HEALTH/SOCIAL WORK

Mini-Mental State Examination

MENTAL HEALTH/SOCIAL WORK

Minor Operative Note

SURGICAL/PROCEDURES/ANESTHESIA

Missoula-Vitas Quality of Life Index

LONG TERM CARE /NURSING HOME

Moderate Sedation Record

SURGICAL/PROCEDURES/ANESTHESIA

Morse Fall Scale

NURSING

MPEC Nurse Triage

NURSING

MRSA Swab Consent

NURSING

Myocardial Infarction Thrombolytic Therapy

CARDIOLOGY/PULMONARY

Neurology EMG Report

SPECIALTIES

Neurology Screen Parkinson Rating Scale (Unified)

SPECIALTIES

NIH Stroke Scale Assessment

CARDIOLOGY/PULMONARY

Non-Formulary Statins Qualification Assessment

GENERAL

Nurse Adenosine Pre-Thallium Stress Test

CARDIOLOGY/PULMONARY

Nurse Cardiac Risk Factor

CARDIOLOGY/PULMONARY

Nurse CPR Record

CARDIOLOGY/PULMONARY

Nurse Health Maint & Disease Prevention

SCREENING/EDUCATION

Nurse Hearing Screen

AUDIOLOGY/SPEECH

Nurse LTC Note

LONG TERM CARE /NURSING HOME

Nurse LTC Referral Summary

LONG TERM CARE /NURSING HOME

Nurse Med/Surge Observation

SURGICAL/PROCEDURES/ANESTHESIA

Nurse Outpatient Substance Abuse Treatment

MENTAL HEALTH/SOCIAL WORK

Nurse Prostate Screen

SPECIALTIES

Nurse Rehabilitation Note

REHABILITATION

Nurse Seclusion and Restraint Check-Up

MENTAL HEALTH/SOCIAL WORK

Nurse Substance Abuse Admission

SUBSTANCE ABUSE

Nursing Acute Care Admission

NURSING

Nursing ADL Daily Care

NURSING

Nursing ADL Flowsheet

NURSING

Nursing Admission Assessment

NURSING

Nursing Assessment IV

NURSING

Nursing Cardiac Monitoring Note

CARDIOLOGY/PULMONARY

Nursing Cardiac Note

CARDIOLOGY/PULMONARY

Nursing Discharge Note

NURSING

Nursing Discharge Summary II

NURSING

Nursing Geriatric Extended Care Admission Note

LONG TERM CARE /NURSING HOME

Nursing Heparin Protocol Note

NURSING

Nursing Home Referral

LONG TERM CARE /NURSING HOME

Nursing ICU Reassessment

NURSING

Nursing Post-Op Initial Assessment

NURSING

Nursing Reassessment Form Acute

NURSING

Nursing Review of Admission

NURSING

Nursing Shift Assessment I

NURSING

Nursing Shift Documentation

NURSING

Nursing Specialty Clinic

SPECIALTIES

Nursing Transfer Summary II

NURSING

Nursing Treatment Plan

NURSING

Nutrition Assessment

NUTRITION (DIETETICS)

Nutrition Assessment Note (SOAP)

NUTRITION (DIETETICS)

Nutrition Inpatient Follow-Up

NUTRITION (DIETETICS)

Nutrition Inpatient Moderate/Severe

NUTRITION (DIETETICS)

Nutrition Outpatient Education

NUTRITION (DIETETICS)

Nutrition Outpatient Follow-Up

NUTRITION (DIETETICS)

Nutrition Subjective Global Assessment

NUTRITION (DIETETICS)

Nutrition Support Nurse Educator

NUTRITION (DIETETICS)

Observation Database

NURSING

OMFS Admission Note

DENTAL

OMFS Clinic Note

DENTAL

OMFS Consultation Note

DENTAL

OMFS Inpatient Progress Note

DENTAL

OMFS Post Surgical Note

DENTAL

OMFS Pre-Surgical Note

DENTAL

Ophthalmology Assessment

SPECIALTIES

Ophthalmology Optometry Assessment

SPECIALTIES

Oral Examination and Treatment Plan

DENTAL

Organ Donor Referral Form

GENERAL

Orthopedic Follow-Up

SPECIALTIES

Orthopedic History Intake

SPECIALTIES

Outpatient Nutrition Clinic Note

NUTRITION (DIETETICS)

Outpatient Therapy Note

MENTAL HEALTH/SOCIAL WORK

Pain Assessment

NURSING

Pain Assessment Analgesic PRN

NURSING

PAR Score

NURSING

Parenteral Nutritional Note

NUTRITION (DIETETICS)

Patient Controlled Analgesia

NURSING

Patient Education Record

SCREENING/EDUCATION

Patient Transfer Assistance Assessment

NURSING

Patient/Family Education Assessment

SCREENING/EDUCATION

Periodontic Examination Note

DENTAL

Periodontic Treatment Note

DENTAL

Pharmacy Discharge Instructions

SPECIALTIES

Physical Therapy Exam Note

REHABILITATION

Physician Discharge Note

GENERAL

Physician’s CNH Referral

LONG TERM CARE /NURSING HOME

PolyTrauma/Brain Injury Clinical Pathway

REHABILITATION

Post Fall Assessment

NURSING

Post Op Progress Note

SURGICAL/PROCEDURES/ANESTHESIA

Post-Op Telephone Questionnaire

NURSING

Pre-Anesthesia Assessment

SURGICAL/PROCEDURES/ANESTHESIA

Pre-Op Nursing Screen Assessment

SURGICAL/PROCEDURES/ANESTHESIA

Preoperative/Pre-Procedure Checklist

NURSING

Pressure Ulcer Report

SPECIALTIES

Primary Care History & Physical

PRIMARY CARE

95 guidelines

PRIMARY CARE

Primary Care Nursing Assessment

PRIMARY CARE

Pronouncement of Death Note

GENERAL

Prosthodontic Implant Note

DENTAL

Psychiatric Assessment

MENTAL HEALTH/SOCIAL WORK

Psychiatry Discharge Note

MENTAL HEALTH/SOCIAL WORK

Psychiatry Follow Up Note

MENTAL HEALTH/SOCIAL WORK

Pulmonary Function Test Interpretation

CARDIOLOGY/PULMONARY

Readiness To Learn

LONG TERM CARE /NURSING HOME

Recreation Therapy Assessment

REHABILITATION

Recreational Therapy Note

REHABILITATION

Recreational Therapy Plan

REHABILITATION

Rehabilitation Brief Note

REHABILITATION

Removable Prosthodontics Note

DENTAL

Renal Hemodialysis Treatment

SPECIALTIES

Renal Nurse Dialysis Plan

SPECIALTIES

Resident Skin Assessment

LONG TERM CARE /NURSING HOME

Resident Supervision Note for Attending

GENERAL

Respiratory Bronchoscopy

SPECIALTIES

Respiratory Education Airway Pressure

SPECIALTIES

Respiratory Sleep Apnea

SPECIALTIES

Respiratory Therapy Comprehensive

SPECIALTIES

Restraint Assessment

NURSING

Restraint Renewal Note

GENERAL

Rheumatology Exam & Minor Procedure Note

SPECIALTIES

Routine Donor Referral Form

GENERAL

Scheduled Clinic Visit Note

NURSING

Screen AIMS (Abnormal Involuntary Movement Scale)

MENTAL HEALTH/SOCIAL WORK

Screen Barnes Akathasia

MENTAL HEALTH/SOCIAL WORK

Screen Brief Prv Health/Chronic Disease

SCREENING/EDUCATION

Screen CIWA Withdrawal

SUBSTANCE ABUSE

Screen Comprehensive Prev Health/Chronic Disease

SCREENING/EDUCATION

Screen Dyskinesia Monitoring

MENTAL HEALTH/SOCIAL WORK

Screen Hamilton Depression

MENTAL HEALTH/SOCIAL WORK

Screen Mini-Mental Status Exam

MENTAL HEALTH/SOCIAL WORK

Screen Quality of Life

MENTAL HEALTH/SOCIAL WORK

Screen Simpson-Angus

MENTAL HEALTH/SOCIAL WORK

Screen Yesavage Geriatric Depression

MENTAL HEALTH/SOCIAL WORK

Screen Yesavage Geriatric Depression Long Form

MENTAL HEALTH/SOCIAL WORK

Screen Zung Self-Rating Depression

MENTAL HEALTH/SOCIAL WORK

Self Medication Program Assessment

NURSING

Shift Assessment/Summary

NURSING

Short Blessed Test

MENTAL HEALTH/SOCIAL WORK

Sleep Apnea Follow Up Note

SPECIALTIES

Smoking Cessation Initial Note

SCREENING/EDUCATION

Social Work Note

MENTAL HEALTH/SOCIAL WORK

Social Work Post Discharge Follow-up Note

MENTAL HEALTH/SOCIAL WORK

Special Procedure Note

SURGICAL/PROCEDURES/ANESTHESIA

Special Transportation Mode Note - not soc work

GENERAL

Speech Pathology – Clinical Swallow Evaluation

AUDIOLOGY/SPEECH

Speech Pathology Note

AUDIOLOGY/SPEECH

Spinal Cord Injury ADL

NURSING

Spinal Cord Injury Home Care IDT

HOME HEALTH

Spiritual Evaluation

MENTAL HEALTH/SOCIAL WORK

St. Louis University Mental Status (SLUMS)

MENTAL HEALTH/SOCIAL WORK

Standalone Morse Fall Risk

NURSING

Stroke/Neuro Clinical Pathway – CIIRP

REHABILITATION

Substance Abuse Admission

SUBSTANCE ABUSE

Suicide Assessment

MENTAL HEALTH/SOCIAL WORK

Surgical Admission

SURGICAL/PROCEDURES/ANESTHESIA

Therapeutic Phlebotomy Note

SPECIALTIES

Thoracic Surgery Progress Note

SURGICAL/PROCEDURES/ANESTHESIA

Transplant Candidate

MENTAL HEALTH/SOCIAL WORK

Treatment Plan

MENTAL HEALTH/SOCIAL WORK

TU Shift Assessment

NURSING

Vascular Lab – Carotid

CARDIOLOGY/PULMONARY

Venous Duplex Scan Lower Ext.

SURGICAL/PROCEDURES/ANESTHESIA

Venous Duplex Scan Upper Ext.

SURGICAL/PROCEDURES/ANESTHESIA

Vocational Rehabilitation Consult

SPECIALTIES

Voice Evaluation

AUDIOLOGY/SPEECH

Walk-In Disposition

NURSING

Wound Assessment

NURSING

Wound Assessment 2

NURSING

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